Healthcare Provider Details

I. General information

NPI: 1275777328
Provider Name (Legal Business Name): DERBY EMOTIONAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 06/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 E OSAGE SUITE 300
DERBY KS
67037-2290
US

IV. Provider business mailing address

1721 E OSAGE SUITE 300
DERBY KS
67037-2290
US

V. Phone/Fax

Practice location:
  • Phone: 316-788-1907
  • Fax: 316-788-1941
Mailing address:
  • Phone: 316-788-1907
  • Fax: 316-788-1941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1527
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number74173
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4695
License Number StateKS
# 4
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1527
License Number StateKS

VIII. Authorized Official

Name: ALICIA ANN MYERS-LANDSVERK
Title or Position: PHD, LSCSW
Credential: LSCSW
Phone: 316-788-1907